1 Jim Roxburgh, RN, MPA Director, Dignity Health Telemedicine Network
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Jim Roxburgh, RN, MPA Director, Dignity Health Telemedicine Network
Disclosure
Jim Roxburgh, and Dignity Health have reported no
relevant financial interest/relationship with any commercial entities that may have ties to this presentation.
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Efficiency is
doing things
right
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Effectiveness is
doing the right
things
Objectives
• Get familiar with the available telemedicine technology
• Identify advances in telemedicine
• Detail aspects of how telemedicine works in the acute, ambulatory and home settings
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CTA
Angioplasty balloon Post procedure
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250,000
90,000
Leverage Telehealth Services to Costs, Quality Outcomes
& Enhance the Patient Experience
Growth of the Internet
Benefits of Telemedicine
Improved Access
Cost Efficiencies
Improved Quality
Patient Demand
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DHTN PROGRAM GOAL
Provide timely access to high quality specialized healthcare services that are not readily
available
“LEAD WITH SERVICE…
DELIVER ON QUALITY”
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Director
Telehealth Assistant
Senior Analyst Telehealth Solutions Manager
Medical Director
Medical Director Stroke
Medical Director ICU
Medical Director Psych
Physician Leader Ambulatory/LTC
Program Manager
RN Coordinator
Neuro/Stroke
RN Coordinator
ICU
RN Coordinator
Psych
RN Lead
Ambulatory/LTC
DHTN Team
Denise Pimintel, RN, MN, MS, CCRN RN COORDINATOR - TELEICU
John MacKenzie, RN, BSN RN COORDINATOR – MENTAL HEALTH SPECIALIST
Jim Roxburgh, RN, RRT, MPA DIRECTOR
Nafees Coleman, MS, PMP SENIOR ANALYST
Tammy Mitchell, RN,MS, CCRN RN COORDINATOR - TELESTROKE
Alan J. Shatzel Jr., DO, FAASM President & Chairman, Mercy Medical Group Inc.
Medical Director, Dignity Health Neurological Institute Medical Director, Dignity Health Telemedicine Network
The Facts…
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• The Mercy Telehealth Network(MTN) was founded in 2008
• The MTN officially became the Dignity Health Telemedicine Network (DHTN) in 2014
• The DHTN provides services to 39 Hospitals/Clinics/Long Term Facilities; 72 End Points (Telemedicine Robots)
• The DHTN provides 13 different specialty services
• The DHTN provides > 10,000 consults annually
The Facts…
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The DHTN one of the largest
Acute Care Telemedicine
Networks in the United States (# of Clinical Sessions & Services per End Point)
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DHTN Services ACUTE
• Stroke/Neurology • Mental Health • Critical Care • Nephrology • Pediatrics • Newborn Care • Cardiology • Infectious Disease
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CLINIC/LTC • Geriatrics • Neurology • Endocrinology • Pulmonology • Thoracic Surgery • Oncology
TRANSITIONAL • CHF • COPD • Diabetes • Post Surgery • Wound Care
HOME • CHF • COPD • Diabetes • Post Surgery • Wound Care
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TELE-INTENSIVIST
TELE-NEUROLOGIST
TELE-NEPHROLOGIST
Can change individual settings & see profile information
Type message or attach pics
Secure Texting
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Patient Care Need
Call Dignity Health Transfer Center @
1(888)637-2941
Page/Call Psychiatrist
Page/Call Intensivist
Page/Call Neurologist
Page/Call Nephrologist
Page/Call Neonatologist
Page/Call Pediatrician
Page/Call Geriatrician
RAPID RESPONSE
DOCUMENTATION REPORTING IMAGES
TELESTROKE
AVERAGE RESPONSE
TIME 2 minute call back 6 minute beam in
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tPA Rate
24%
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When To Call For A TeleNeurology Consult
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PRACTICE!! PRACTICE!!! PRACTICE!!!!
PRACTICE!! PRACTICE!!! PRACTICE!!!!
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Transfer Center Checklist
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Partner Site Telestroke Checklist
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Partner Site Telestroke Checklist
(continued)
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Endovascular Treatment in Acute Ischemic Stroke
• Berkhemer OA, et al. A randomized trial of intraarterial treatment for acute ischemic stroke (MR CLEAN). N Engl J Med 2015
• Goyal M, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke (ESCAPE). N Engl J Med 2015
• Campbell B, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection (EXTEND-IA). N Engl J Med 2015
• Saver J, et al. Invited Presentation: Solitaire FR as Primary Treatment for Acute Ischemic Stroke (SWIFT PRIME). ISC 2015
Endovascular Treatment in Acute Ischemic Stroke
• Indications: • Acute Ischemic Stroke within 6 hours of symptom onset/LKW or unknown
symptom onset/LKW or wake up stroke with normal CT Head & disabling neurologic deficits
• Age > 18 • NIHSS > 2 or disabling neurologic deficits irrespective of NIHSS • Contraindications to IV tPA • Baseline modified rankin score (mRS) < 3 • ASPECTS Score > 6 AND suspected large vessel occlusion AND/OR hyperdense
MCA, MCA dot or basilar artery sign on CT head • CTA/MRA with intracranial/extracranial ICA, M1, M2, A1 or A2 occlusion AND
moderate to good collaterals AND/OR CT/MR Perfusion with core infarction < 50 ml, ischemic penumbra > 10ml & mismatch ratio > 1.2 or > 1.8 if using the RAPID Automated Software
• CTA or MRA with basilar thrombosis within 12 hours of symptom onset/LKW
Drafted: Asad A. Chaudhary, MD 2/15/2015
Endovascular Treatment in Acute Ischemic Stroke
• Contraindications: • CT or MRI evidence of hemorrhage • CT hypodensity or MRI hyperintensity > 1/3 of the MCA territory (or in other
territories, > 100ml of tissue) • ASPECTS Score < 6 • Baseline modified rankin score (mRS) > 3 • CTA/MRA with no intracranial or extracranial ICA, M1, M2, A1 or A2 occlusion
AND/OR poor collaterals AND/OR CT/MR Perfusion with core infarction > 50 ml, ischemic penumbra < 10ml & mismatch ratio < 1.2 or < 1.8 if using the RAPID Automated Software
• Non-disabling neurologic deficits • Recent history of large ischemic stroke in the same territory (< 14 days)* • DNR Comfort Care or on Hospice
Drafted: Asad A. Chaudhary, MD 2/15/2015
Endovascular Treatment in Acute Ischemic Stroke
• Relative Contraindications: • Carotid dissection or complete cervical carotid occlusion that might require
stenting at the time of mechanical thrombectomy* • Unable to transfer to endovascular capable facility to achieve successful
reperfusion by 8 hours from symptom onset/LKW* • H/O connective tissue disorder like Marfans or Ehler Danlos Syndrome* • Terminal illness or co morbid conditions with life expectancy < 1 year* • *at the discretion of the neurointerventionalist and neurologist • Berkhemer OA, et al. A randomized trial of intraarterial treatment for acute
ischemic stroke (MR CLEAN). N Engl J Med 2015 • Goyal M, et al. Randomized assessment of rapid endovascular treatment of
ischemic stroke (ESCAPE). N Engl J Med 2015 • Campbell B, et al. Endovascular therapy for ischemic stroke with perfusion-
imaging selection (EXTEND-IA). N Engl J Med 2015 • Saver J, et al. Invited Presentation: Solitaire FR as Primary Treatment for Acute
Ischemic Stroke (SWIFT PRIME). ISC 2015
Drafted: Asad A. Chaudhary, MD 2/15/2015
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TeleStroke Hospital Case Study One Year Comparison
CY 2011 CY 2012
# of ED Visits (approx) 50,000 50,000
Ischemic Stroke 14 169
tPA 9 28
tPA Cont. Margin (approx) $7,000 $7,000
Total Contribution Margin $63,000 $196,000
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EMS TRIAL
ICU “Round & Respond”
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Remote Specialist Service
24/7/365
InTouch Health Remote Presence
Services available by ALL qualified Specialists (Pulmonologists, Cardiologists, Neurologists, Surgeons, etc…)
• Labs
• Meds
• vital signs
• EKGs
• Wave Forms
• Images
• Ventilator Settings
• Real Time
Assessment and
Communication from
any location
• Ability to consult with
multiple Specialists
via Multipresence™
Airstrip Bedside Monitoring
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Dignity Health – TeleICU – “Round and Respond” Immediate access to live and
historic patient data
Local and remote
critical care team on
rounds
Critical care
or in-patient
Leveraging shared patient data and connectivity…
…for better data driven decision-making
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Eric – This is a perfect slide – can we remove all the company
Logos?
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ICU
65/FEMALE
Gonzales, Marie
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Balancing Resources w/ Remote Coverage
MGH
Traditional Model
SNMH WMH
MTMC
Affiliates census below capacity
Tertiary facility overloaded
Proactive Model
Balance Bed Capacity Across
System
“Keep it within our system, but do not overload the tertiary care center”
MSJMC
SNMH WMH
MTMC
MGH MSJMC
TeleICU Case Study (One Year Comparison)
CY 2013 CY 2014
# of ICU Beds 6 6
Severe Sepsis & Shock Mortality
45% 19.4%
Ventilator Day ALOS 2.8 1.4
ICU Contribution Margin Increase
NA $868,255
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Transfers (One Year Comparison)
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2013 Transfers Out from Woodland Memorial Hospital* • Total Transfers 213
– ED Transfers 142 – ICU Transfers 28
*Source: AMAP & Teletracker; transitioned from AMAP to Teletracker software 2014 Transfers Out from Woodland Memorial Hospital** • Total Transfers 139
– ED Transfers 87 – ICU Transfers 25
**Source: Teletracker
TELEMENTAL HEALTH
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Last night I had a young man and his
father come into Methodist ED as the 19
yr old son was beginning to experience
active symptoms of his schizophrenia in
the last week and beginning to
decompensate because of it
I spoke to Dr. Nie (the psychiatrist) on the line, presented the patient case to
her and then had her speak to the patient using the telephone headset for
his privacy.
Within an hour, the pt had the
medication change, avoided a 5150, a
potential lengthy hospital stay and was
able to return to his home with father.
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Joint Commission Standard Patient flow through the emergency department
Requirements
Standards LD.04.03.11 and PC.01.01.01 are revised standards that
address an increased focus on the importance of patient flow in
hospitals.
EP 6. This element of performance went into effect January 1, 2014:
The hospital measures and sets goals for mitigating and managing the
boarding of patients who come through the emergency department.
Note: Boarding is the practice of holding patients in the emergency
department or another temporary location after the decision to admit or
transfer has been made. The hospital should set its goals with attention
to patient acuity and best practice; it is recommended that boarding
time frames not exceed 4 hours in the interest of patient safety
and quality of care.
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Mark Twain Medical Center Family Clinic
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Geriatric House Call Telemedicine
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The Telehome Kit
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Bluetooth
BP & Weight
Remote Patient Monitoring
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Patient @ Home Health Coach
Home Monitoring/Triage
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Chronic Care Management (CCM)
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Medicare will pay for chronic care management (CCM) services – non- face-to-face services to Medicare beneficiaries who have multiple, significant, chronic conditions (two or more) – effective January 2015.
Chronic Care Management (CCM)
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Chronic care management services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management.
Chronic Care Management (CCM)
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• For the first quarter the payment rate is $40.39 for CCM that can be billed up to once per month per qualified patient.
• CCM services are to be reported with CPT 99490.
Billing Requirements
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• CCM services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:
• Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
• Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensating, or functional decline
Billing Requirements
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• Comprehensive care plan established, implemented, revised, or monitored.
• The CCM and non-face-to-face portion of the Transitional Care Management services provided by clinical staff incident to the services of a practitioner may be furnished under the general supervision of a physician or other practitioner.
Billing Requirements
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• Use a Certified EHR
• Maintain an electronic care plan
• Ensure beneficiary access to care
• Facilitate transitions of care
• Coordinate Care
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THANK YOU!!